The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia on it. What would the nurse expect to find on further assessment? (Select all that apply.)
a. A firm fundus the size of a grapefruit
b. A full bladder
c. Retained placental fragments
d. Vital signs indicative of shock
e. A soft, boggy fundus
ANS: B, E
Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterus that is boggy.
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Which of the following statements is true about the role of grandparents?
a. The usefulness of grandparents declined with the advent of the industrial age. b. Today, many grandparents are the primary caregivers of their grandchildren. c. The value of grandparents is to provide gifts to younger family members. d. Traditionally, parents are subordinate to the grandparents in caregiving.
The similarities between the Omaha System and the NANDA taxonomy are that both contain which of the following?
1) Evaluation tools expressed in standardized language 2) Nursing diagnoses expressed in standardized language 3) Diagnoses, outcomes, and interventions 4) Labels that are intended for use in any healthcare setting
The nurse recognizes that which one of the following statements is true with regard to the for-mulation of nursing diagnoses?
1. The diagnosis should identify a "cause and effect" relationship. 2. The diagnosis must remain constant during the client's hospitalization. 3. The etiology of the diagnosis must be within the scope of the health care team's practice. 4. The diagnosis should include the problem and the related contributing conditions.
The client who hesitates 30 seconds before responding to any question is described as having
a. blunted affect. b. latency of response. c. paranoid delusions. d. poverty of speech.